When a Medicare provider or supplier’s Medicare billing privileges are revoked, commonly called a Medicare revocation, the provider or supplier must ask the following questions: Why? When? Will there be collateral consequences? What are the appeal rights?
Why? Federal regulations provide 22 distinct reasons that the Centers for Medicare & Medicaid Services (CMS) may use to revoke a healthcare provider’s or supplier’s Medicare billing privileges. Some of the most common revocation reasons are noncompliance with Medicare enrollment requirements, felony convictions, and failures to respond to requests for medical records. A particularly severe revocation reason is an abuse of billing privileges because it means that CMS has found that the provider or supplier has engaged in a “pattern or practice of submitting claims that fail to meet Medicare requirements.” The reason for the revocation can affect both the appeal process and the effective dates of the revocation.
When? Two dates are most important: the effective date and the length of the reenrollment bar. The effective date is the date that the revocation begins. For some revocations, the effective date will be 30 days after the letter informing the provider or supplier of the revocation. However, revocations can also be retroactive. For example, in 2021 CMS may revoke a provider for a felony conviction from 2017 and back-date the revocation to begin in 2017. This may mean that all claims for the provider’s services from 2017 to the present will be denied and overpayments sought. The reenrollment bar is the length of time that a revoked provider or supplier must wait before they can reenroll in Medicare. In general, CMS may set a reenrollment of between 1 and 10 years, depending on the severity of the denial reason. However, reenrollment bars are very often initially set at the maximum of 10 years.
Will there be collateral consequences? Medicare revocations can have devastating and far-reaching consequences. First, the provider is no longer eligible to bill Medicare and, depending on the effective date of the revocation, may face years of retroactively denied claims and overpayment demands. CMS may also decide to place a revoked provider on the CMS Preclusion List, which labels the provider a “bad actor” and cuts off their ability to bill Medicare Part C and Part D. A Medicare revocation or placement on the Preclusion List may also cause commercial carriers to terminate participation agreements with a provider and can cause issues with licensing, certification, and staff privileges, depending on the nature of the revocation.
What are the appeal rights? Because of the consequences of a Medicare revocation, a provider or supplier who has been revoked should carefully consider their appeal rights. All Medicare revocations have a right to reconsideration by CMS, review by an Administrative Law Judge (ALJ), appeal to the Departmental Appeals Board (DAB), and filing in federal court. Some revoked providers and suppliers may also have the ability to submit a Corrective Action Plan (CAP) or have the opportunity to negotiate the revocation or the length of the reenrollment bar, depending on the nature of the case and the strategy pursued. It is also important to note that, where a revocation is reversed or rescinded, claims that were denied due to the revocation are not automatically paid and must be appealed separately. An experienced healthcare attorney can help navigate the complexities and the ramifications of a revocation and the appeals process.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in appealing a revocation of Medicare billing privileges. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.